Findings
Our review of the literature indicated that responsiveness is a rather fuzzy concept, with a range of meanings and definitions evident across different fields of the literature. We identified three distinct but overlapping conceptualisations of responsiveness in the literature, corresponding to domains of literature relating to service quality; inequalities and the needs of diverse groups (in health or other services); and consumerism and patient involvement.
Service quality
Responsiveness has a long history of being considered as a core element of service quality.34 Service quality has been defined as the ability of the organisation to meet or exceed customer expectations.35 Parasuraman and colleagues’ widely accepted model of service quality includes five key dimensions: tangibles (features of the service environment); reliability; responsiveness; assurance (the extent to which the organisation and its employees are perceived as credible and trustworthy); and empathy. Within this context, responsiveness has been defined as an organisation’s employees’ ‘willingness to help customers and provide prompt service’ (p. 23).35
Service quality is seen as important for customer-serving organisations in marketing,36 achieving success and profitability through helping to attract and retain customers,37 and promoting customer satisfaction. Responsiveness is recognised as particularly important to the public image of customer-serving organisations; in the UK, the Institute of Customer Service38 makes a high-profile annual People’s Choice award for ‘Most Responsive Organisation’.
The notion of responsiveness as an element of service quality also features in the health literature. Several papers speak of responsiveness as part of a high-quality service, and as a feature of customer service or interactions between staff and patients. For instance, in a qualitative study of patients’ expectations and experiences of public and private providers, patients were found to expect more responsiveness and better quality of care and to be willing to pay for it.39 A study of predictors of hospital patient satisfaction ratings in the USA found that nursing staff communication with patients had an important bearing on perceived responsiveness.40
The field of work on service quality has generated a number of measures; the most widely used of these is the SERVQUAL scale.35,41 This incorporates the five dimensions of service quality described above. The SERVQUAL scale includes a subscale of four questions to measure responsiveness:
P10: employees of XYZ tell you exactly when services will be performed
P11: employees of XYZ give you prompt service
P12: employees of XYZ are always willing to help you
P11: employees of XYZ are never too busy to respond to your requests.
SERVQUAL has been used extensively across a wide range of settings to measure service quality, either in its original form or adapted to the specific setting.42,43
The SERVQUAL dimensions have been found to be applicable and stable in the measurement of service quality in health care,44–46 and specifically in primary care,47 with responsiveness remaining a core element of service quality in this context. SERVQUAL has been adapted and used in studies of service quality in a range of health-care settings48–51 but has not found wide application in the context of primary care. A version of SERVQUAL designed to assess the quality of hospital services has been developed,52 and SERVQUAL has been adapted for use in a primary care clinic in the USA.53 The revised scale was assessed for factor structure, reliability and validity; responsiveness remained a core element of the scale. Four questions on responsiveness were included, relating to prompt service; employee willingness to help; staff never too busy to respond to requests; and convenient opening hours.
The conceptualisation of responsiveness as an element of service quality has several key implications. First, responsiveness is tied to customer service – the quality and promptness of interactions between employees and customers (or between staff and patients) – rather than other features of the organisation. Second, the notion of service quality focuses on improving customer experience, exceeding expectations, increasing satisfaction, and even ‘delighting’54 the customer. It is seen as a route to attracting and retaining customers, and increasing market share. Within this literature, responsiveness is not seen as a ‘duty’ or essential feature of an organisation, but as a ‘value adding’ feature of service. Third, the focus is not on diverse or disadvantaged groups, but on improving the experience of all customers/patients.
Inequalities and the needs of diverse groups
The concept of responsiveness is also prominent in the field of work relating to health inequalities. Seminal work undertaken by the World Health Organization (WHO) in the late 1990s and early 2000s identified responsiveness as one of the three intrinsic goals of health systems (along with good health and fair financing).55 Responsiveness involves health systems meeting the needs of the patients they serve, and is based on the idea that there are fundamental needs, or basic human rights, that health systems should meet for all patients. These needs are seen as relating to the non-clinical domains of health service provision. Responsiveness is defined as ‘how well the health system meets the legitimate expectations of the population for the non-health enhancing aspects of the health system. It includes seven elements: dignity, confidentiality, autonomy, prompt attention, social support, basic amenities, and choice of provider’ (p. 1).56 It is suggested that if a health system is responsive, the interactions that people have within the health system may improve their well-being, irrespective of improvements to their health.57
The WHO argues that the measurement of responsiveness is essential to assessing the performance of health systems, and importantly, involves measuring ‘both the overall level of achievement (average over the whole population) as well as the distribution (equitable spread of this achievement to all segments of the population)’ (p. 1).56 It is clear that this conceptualisation of responsiveness involves fairness and avoiding inequalities across the patient population.
By their definition, the WHO sought to measure responsiveness objectively by looking at how patients perceive what happens in their experience of using health care.56 They developed a responsiveness instrument58 and tested it across 35 countries. Factor analysis revealed the seven elements used in their definition, above.59 Levels of responsiveness were measured using a patient-report questionnaire, split into two sections: patients were asked, first, to rate their experience with the system, and second, to rate how important each element was to them. Each element comprised 3–7 questions.56 Questions were formatted to assess the extent to which patients felt their needs for each dimension were met, for example:
In the last 12 months, how often did the office staff, such as receptionists or clerks there, treat you with respect?
always
usually
sometimes
never.
Data on inequalities in distribution of responsiveness were generated through surveys completed by key informants in each country; informants were asked about whether or not they felt that particular patient groups were discriminated against with regard to responsiveness in their country.60
The WHO responsiveness measure has been widely used in studies to assess health system responsiveness internationally.61,62 This has included work to identify predictors of health system responsiveness; evidence suggests that health-care expenditures per capita, and educational development, are positively associated with responsiveness, while public sector spending is negatively associated with responsiveness.63 The WHO definition has also been used as the basis of work to identify unmet needs in disadvantaged groups, including a literature review to identify the extent to which people who access mental health services were not having their needs met.64
The WHO work focuses on responsiveness of health systems, rather than individual providers such as GP practices. The WHO definition was adapted for primary care by Canadian researchers to produce a definition of responsiveness as the ‘ability of the primary care unit to provide care that meets the non-health expectations of users in terms of dignity, privacy, promptness, and quality of basic amenities’ (p. 341).65 They argued that the operationalisation of responsiveness was problematic due to lack of distinctness from other concepts such as whole-person care. Their earlier work to develop national indicators suggested two core questions to ask about responsiveness: ‘Are patients satisfied that the Primary Health Care organization and providers respect their right to privacy, confidentiality and dignity? Are patients confident that PHC organizations and providers are responsive to their culture and language needs?’66
The focus in health on responsiveness as involving providing services equitably and meeting the needs of all, across diverse groups, is echoed in work on responsiveness in the field of education. Responsiveness to learners’ needs has been considered in terms of meeting individual student needs, information, support, respect and opportunities to air views; these dimensions have been included in the National Learner Satisfaction Survey.67
As discussed earlier, arguments for the need to promote responsiveness in primary care tend to draw heavily on the inequalities agenda with a recognition that responding to specific groups’ needs might help to reduce inequalities.68 However, needs are framed in a slightly different way from the notion of universal legitimate expectations that is central to the WHO work. Instead, the focus is on the diverse needs of different patient groups, and ensuring that individual patient needs are met through individualised and proactive care.69,70 Alignment with the needs of different patient groups is seen to be important, and there has been particular focus on the need for cultural alignment with minority groups. Research has shown how cultural self-reflection and self-awareness on the part of staff can be helpful, and how developing a reciprocal understanding of needs can lead to a flexible responsive service.71 However, the evaluation of a human immunodeficiency virus mental health service that actively valued cultural responsiveness (acknowledging clients’ cultural identities, taking their beliefs, norms and values into account in the interventions) struggled to separate out whether cultural responsiveness or integrated care affected observed findings independently or in combination.72
With responsiveness defined as an approach to reducing inequalities, the onus is on providers to ensure that they understand their practice populations, and can segment them based on need.13,73 There is also an emphasis on finding proactive ways to reach out to marginalised groups who may find it difficult to access health care.74,75
One challenge raised within this field relates to the nature of needs, expectations and demands. A distinction has been made between needs and demands in the context of health needs assessment, and this distinction may be useful in conceptualising needs in relation to non-clinical aspects of care. Under this framework, needs have been described as areas in which there is capacity to benefit, and as ‘normative’, i.e. they should be met.76 Demands are what patients ask for (implicit in this is the notion that it may or may not be appropriate for providers to respond to demands). One study, exploring the views of staff about needs and demands in relation to public services, concluded that responsiveness related to identifying unmet needs (with a focus on cultural needs), and finding the right balance of managing needs and demands.77 The authors define needs as rational demands (consistent and evidence-based) as opposed to demands as ‘desires’. They argue that public services should try to meet users’ demands, but that other forms of demand management may be required to realign these demands with users’ needs. They suggest that practical demand management in needs-based public service requires knowledge of users’ demand for services; content analyses of users’ demands to identify any misinformed demands; conversion of any misinformed demands into evidence-based specifications of needs; and formulating coherent evidence-based demands on behalf of users who cannot do so themselves. They acknowledge the tension between needs assessment being professionally controlled rather than responsive to users.77
The key implications of considering responsiveness as relating to inequalities include, first, that responsiveness relates to a broad set of non-clinical features of service organisation and delivery. Second, responsiveness is seen as a core duty of an organisation – providing a level of service that meets patients’ needs fairly across all patient groups (although there are some differences in emphasis in relation to whether this refers to basic universal needs or specific needs of different patient groups or individual patients, and a recognition that responsiveness may involve managing demands). Third, the focus is on diverse groups and ensuring that no patient groups are disadvantaged in their experiences of receiving services. Under this definition, achieving responsiveness requires more than just good customer service; it requires an understanding of population characteristics, and proactive planning to meet needs and avoid disadvantage. Finally, measures of responsiveness need to pick up on differentials between different groups, and identify whether or not certain groups are disadvantaged (e.g. BME groups, deprived groups, males, females).
Consumerism and patient involvement
The focus on responsiveness has been linked with the shift towards consumerism and consumer demand for services that are tailored to individual needs. Responsiveness is seen as a way of bringing the NHS in line with other services such as retail and banking, which are geared towards being adaptable to individual needs, and offering more convenience, choice and flexibility. Fundamental to this shift is the idea that services should be geared to the interests of users rather than the convenience of producers.78 Increasing user participation is described as core to this; an advisory document reporting on group discussions and a citizens’ forum found that:
Overall, people think that a responsive public service is one that: provides easy and appropriate access to services; encourages the individual to use and shape services in ways that suit them; actively seeks to learn from public involvement and develop services accordingly.70
p. 5
People’s ideas on how public services could be made more responsive included making communication simple and obvious, keeping people informed throughout, involving people as early as possible, and shared responsibilities and shared outcomes.70 User ‘choice’ and ‘voice’ are also seen critical: exit and voice (communicating user demands) have been described as two ‘recuperation’ mechanisms for making organisations responsive.79
In the context of public service and administration literature, responsiveness has been contrasted with collaboration.80 The authors described responsiveness as responding to requests for action or information. They viewed responsiveness as a mostly passive, unidirectional reaction to people’s needs and demands, whereas collaboration was a more active, bidirectional act of participation, involvement and unification of forces between two or more parties. Some definitions of responsiveness in primary care and patient involvement literature are more in line with this notion of collaboration.
Responsiveness in primary care has been defined as synonymous with patient participation, engagement and involvement.81 NAPP suggest that being responsive requires practices to engage with patients; that patient experience is a key part of a responsive practice; and that improved communication and responsiveness are needed for a successful practice and patient participation group (PPG).81 A discussion piece summarising the meaning of responsiveness included involving patients with service planning.74 The authors found two ways that this was enacted. First, some seek to involve patients in the planning of care. Second, others make attempts to reach out to groups who find it difficult to access health care. A Scottish study of Local Health Care Co-operatives highlighted the need to engage patients and local communities, and defined responsiveness in terms of proactively engaging patients in planning services.82
The close link between responsiveness and patient engagement is highlighted by the inclusion in a directed enhanced service (DES) framework on responsiveness of an eligibility criteria relating to engagement with patients,13 as the report states:
Improving access and responsiveness needs to be strongly founded on engagement with patients and should be a dynamic process. Providers should be required to demonstrate active engagement with people and local communities in developing services . . . Providers should demonstrate how they respond to patient feedback and this is to be used to shape and improve services . . . Local Involvement Networks (LINks), the voluntary sector and patient advocacy organisations are all further mechanisms to seek active involvement in service planning, delivery and monitoring.
p. 6
There are limitations to the conceptualisation of responsiveness as dependent on choice, voice and patient involvement. Changing providers is not always cost-neutral for users, and exercising voice adds practical burdens with little reward, hence users who exercise voice may be few, self-selected and apparently ‘unrepresentative’.79 Many people with common health conditions, such as mental health problems, are reluctant or unable to engage in the ‘user movement’, hence undermining the effectiveness of patient involvement.69
The key implications of definitions of responsiveness within the consumerism/patient engagement literature are, first, responsiveness framed in this way is about patients as consumers taking responsibility for defining78 and asserting their needs. The implication of this is that less responsibility is placed upon providers to proactively plan for and support disadvantaged groups. This is in tension to some extent with the notion of responsiveness as a duty of providers and as a way of reducing inequalities (as discussed above). Reliance on patient choice and voice may result in responsiveness to those who are most eloquent and demanding, at the expense of the vulnerable and needy. There has been much focus on the need for groups who are disadvantaged to have a voice, and on providers working to involve, and hear the voices of, ‘seldom-heard’ groups. Second, a distinction can be made within this literature between the notion that responsiveness can be defined as the extent to which providers engage with patients and enable choice and voice, and the view that patient involvement and engagement is a key means of achieving or improving responsiveness (by helping providers better understand patient characteristics and needs, particularly those of groups who are disadvantaged). Third, this suggests that measures of responsiveness should assess aspects of patient choice and engagement, and the extent and quality of dialogue between providers and patients.
Summary and discussion
We have demonstrated that the literature on responsiveness falls into three broad, overlapping themes. Service quality literature speaks of responsiveness as part of a high-quality service. Responsiveness is closely linked with good customer service – providing for customer needs in a quick, efficient and polite manner. Literature on inequalities casts responsiveness as a duty of providers and as involving meeting the needs of all patients across different patient groups. A third body of literature links responsiveness to the shift towards consumerism and patient participation: being a responsive GP practice means engaging with patients, for example, through working with PPGs and involving patients in planning services.
These three distinct conceptualisations of responsiveness have different implications and connotations. With responsiveness conceptualised as service quality, it is seen as something that adds value to a service, and as a way of attracting customers and building market share. It is not seen as a ‘duty’ or essential feature of an organisation, but as a ‘value adding’ feature of service. This conceptualisation has a focus not on diverse or disadvantaged groups, but on improving the experience of all customers/patients. When responsiveness is defined as relating to inequalities, it becomes seen as a core duty of an organisation, and the focus shifts to considering the needs and experiences of disadvantaged patient groups. Conceptualising responsiveness as relating to patient involvement shifts the responsibility away from the provider and sees it as held by or shared with the patient.
In English policy, definitions of and debates about responsiveness reflect the different conceptualisations emerging from these three bodies of literature, as can be seen in the definition presented in the report Improving GP access and responsiveness:7
Practice responsiveness is the way in which a practice communicates and engages with its patients and their carers and responds to their non-clinical needs and preferences, reflecting the different ways in which they might prefer to access the service and an appropriate clinician, book, or indeed cancel an appointment. It includes the practice’s attitude to customer service and friendliness of staff, the environment in which patients wait to be seen and the way in which they interact and support patients from particular groups, such as those with hearing or sight loss or people from a black or minority ethnic background.
It is potentially problematic that the definition of responsiveness in primary care draws on all three conceptualisations of responsiveness, all with different implications about how responsiveness might be achieved and measured, meaning that responsiveness in primary care remains a fuzzy and poorly delineated concept. In subsequent qualitative work, this study sought insight into what responsiveness in primary care actually means to staff and patients, and how it can be measured and then improved.